Impact of Pupil-Decentration on Visual and Refractive Outcomes in Myopic Patients Undergoing High Astigmatic PRK Surgery

<b>Background/Objectives</b>: To compare the visual and refractive outcomes of myopic patients undergoing high astigmatic photorefractive keratectomy (PRK) surgery with and without pupillary decentration of treatment. <b>Methods</b>: In this retrospective study, we reviewed the medical records of myopic patients who underwent PRK surgery for high astigmatism (>3 diopters [D]) between January 2013 and December 2023. The patients were divided into two groups based on whether the surgeon applied pupillary decentration during surgery. Preoperative, intraoperative, and postoperative parameters were compared between the groups. Adjustments were made to account for differences in baseline characteristics and intraoperative parameters. <b>Results</b>: Overall, the study included 575 eyes from 414 patients, of which 79 eyes were treated with pupil decentration. The pupil-decentered group exhibited significantly preoperative higher myopia (subjective spherical equivalent (SEQ) of -5.30 ± 3.12 D vs. -4.26 ± 2.45 D, <i>p</i> < 0.001) and subjective sphere (-3.40 ± 3.13 D vs. -2.31 ± 2.49 D, <i>p</i> < 0.001). Visual and refractive outcomes, including uncorrected visual acuity (UCVA) of logMAR 0.11 ± 0.77 vs. 0.09 ± 0.72 (<i>p</i> = 0.302), best-corrected visual acuity (BCVA) of 0.07 ± 0.92 vs. 0.07 ± 0.82 (<i>p</i> = 0.982), SEQ (-0.33 ± 0.93 vs. -0.19 ± 0.60D, <i>p</i> = 0.094), sphere (0.02 ± 0.98 vs. 0.15 ± 0.67 D, <i>p</i> = 0.142), cylinder (-0.71 ± 0.48 vs. -0.70 ± 0.55 D, <i>p</i> = 0.894), safety index (1.07 ± 0.27 vs. 1.12 ± 0.31, <i>p</i> = 0.236), and efficacy index (0.99 ± 0.31 vs. 1.07 ± 0.35, <i>p</i> = 0.065), showed no significant differences between the two groups. Postoperative outcomes remained comparable after adjusting for baseline and intraoperative parameters. <b>Conclusions</b>: Our findings suggest that, in myopic patients undergoing high-astigmatic PRK surgery, pupil decentration does not lead to superior postoperative visual and refractive outcomes. This highlights that, in this scenario, surgeons can preserve the efficacy and safety of the procedure even without applying pupil decentration.